Tobacco or

Oral HealthWorld Health Organization

An advocacy guide for oral health professionals

Tobacco or

Oral Health:An advocacy guide for oral health professionals

World Health Organization

2

The FDI World Dental Federation

The FDI World Dental Federation is the authoritative worldwideorganisation of dentistry representing more than 700,000 dentists in 137countries around the globe. Founded over a hundred years ago in Paris,the FDI is a federation of national member associations that gather oncea year in a general assembly, the World Dental Parliament. The FDI is inofficial relations with the World Health Organization, the United Nationsand other international organisations.The promotion of optimal oral andgeneral health is a major aim of FDI’s activities; including the promotion ofWHO policies.www.fdiworldental.org

The World Health Organization (WHO)

The World Health Organization, the United Nations specialised agency forhealth, was established in 1948. WHO’s objective, as set out in itsconstitution, is the attainment by all peoples of the highest possible levelof health. Health is defined in WHO’s Constitution as "a state of completephysical, mental, and social well-being and not merely the absence ofdisease or infirmity." WHO is governed by 192 Member States through theWorld Health Assembly.www.who.int or www.who.int/oral_health

World Health Organization

Editors and Authors

Dr Rob H BeagleholePublic Health ConsultantLower Hut, New Zealand

Dr Habib M BenzianDevelopment and Public Health ManagerFDI World Dental FederationFerney-Voltaire, France

Author

Prof Poul Erik PetersenChief Oral Health ProgrammeWorld Health OrganizationGeneva, Switzerland

Dr Carmen Audera Lopez,Medical Officer National Capacity Building,Tobacco Free Initiative,World Health Organization,Geneva, Switzerland

Annemieke Brands,Technical Officer National Capacity Building,Tobacco Free Initiative,World Health Organization,Geneva, Switzerland

Contributors

Dr Örjan ÅkerbergSecretary, Dentistry against Tobacco-SwedenStockholm, Sweden

Dr HR YoonFDI PresidentSeoul, Korea

Dr JT BarnardExecutive DirectorFDI World Dental FederationFerney-Voltaire, France

Dr Neil Campbell,Executive DirectorSouth African Dental AssociationHoughton, South Africa

Dr Bernadette PushpaangaeliSchool of Public Health & Fiji Dental AssociaitonSuva, Fiji

Dr Judith MackayWHO ConsultantHong Kong SAR, China

Dr. Dietmar Oesterreich,Vice PresidentGerman Dental AssociationBerlin, Germany

Dr Ahmed OgwellHead, Division of Noncommunicable Diseases and Head of Secretariat, National Tobacco-FreeInitiative Committee (NTFIC) Ministry of Health Nairobi, Kenya

Dr Mihir N. Shah,Professor of Periodontology and Public Health,Ahmenabad, India

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Disclaimer

The views expressed in this document do not necessarily represent the official views of the FDI WorldDental Federation or the World Health Organization. The editors have done their utmost to ensureaccuracy of all information; however, the inclusion of links and references does not entail recognition orendorsement of information given under these links nor can they be held liable for any wrong information.The use of specific pharmaceutical product names does not imply endorsement or recommendation ofthese products in any way.The terms "developing country" and "developed country" used in this report follow the definitions of theWorld Bank Group.

Acknowledgements:

This Report has been edited by Dr Rob H Beaglehole and Dr Habib M Benzian.

The FDI World Dental Federation is grateful to Unilever Oral Care Ltd for an educational grant that made thispublication possible.

The editors would like to thank the following for their help with the Report: Ms Jo Barber, Mrs LaurenceJocaille and Ms Jenny Lee.

The clinical images were kindly provided by Prof Peter Reichart, Dept of Oral Pathology, Charité DentalClinic, Humboldt University Berlin, Germany.

Warm thanks also to all who provided examples and case stories for chapter 8.

The 4As flow diagram was kindly provided by the Health Development Agency, London, United Kingdom

ISBN Number 0-9539261-4-1

© FDI World Dental Press and the FDI

Published by FDI World Dental Press Ltd, Lowestoft, UK

Printed by Dennis Barber Ltd, UK

No part of this publication may be reproduced, stored in a retrieval system or transmitted in any form orby any means without the written permission of the publisher.

Requests for reprint and other inquiries should be directed to the Head Office of the FDI World DentalFederation, 13 chemin du Levant, 01210 Ferney-Voltaire, France (info@fdiworldental.org).

It is recommended to use the following citation format:FDI / WHO (2005) Tobacco or oral health: an advocacy guide for oral health professionals. Edited byBeaglehole RH and Benzian HM; FDI World Dental Federation, Ferney Voltaire, France / World Dental Press,Lowestoft, UK.

ContentsExecutive Summary 5

Preamble: Judith Mackay 8

Forewords: 10

HR Yoon and JT Barnard, FDI 10

Poul Erik Petersen,WHO 11

1. Introduction: The Extent of the Problem 13

Basic Facts About Tobacco 13

2. The World Health Organization and Tobacco Control 18

Tobacco Free Initiative 18

The Role of Health Professionals in Tobacco Control 20

Approach of the Oral Health Programme,WHO 23

3. The Dentist and Tobacco Control 31

Getting Oral Health Professionals Involved 32

How to Help Patients Stop 33

Setting Up Your Practice for Clinical Tobacco Intervention 37

4. Oral Health Professional Associations and Tobacco Control 41

Advocacy in Public Health 41

Oral Health Professional Associations and Tobacco Control 43

National Dental Associations and Tobacco Control 45

Country Case Studies 48

Dentistry Against Tobacco, a Swedish organisation for oral health professionals 53

5. Recommendations to Oral Health Professional Organisations 55

Forming a Dental Tobacco Advocacy group 55

Resources and Links 58

References 60

Appendix 63

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5

Executive SummaryThis Guide, developed jointly by the FDI World Dental Federation (FDI) and the

World Health Organization (WHO), provides tobacco facts, highlights the

involvement of the FDI and the WHO in tobacco control initiatives, discusses the

role of dentists and other oral health professionals in tobacco control, examines

the role of advocacy, and provides a number of wide ranging recommendations to

move the tobacco control agenda forward.

It is now accepted that helping tobacco users to quit is part of the role of health

professionals, including dentists and other oral health professionals. It is also

formally recognised that tobacco cessation is part of the practice of dentistry. In

addition, oral health professional organisations have a responsibility to engage in

tobacco control initiatives, including supporting political processes that lead to an

environment favourable to health.

The guide is divided into 5 main chapters. Chapter 1 provides a startling

reminder of the dangers posed by tobacco consumption. Tobacco is the second

major cause of death in the world.The death toll from tobacco consumption is now

4.9 million people a year.This figure is expected to climb to 10 million deaths by

2020, with most deaths occurring in developing countries.The impact of tobacco

use on oral health is also illustrated. Tobacco use and its connection with oral

diseases is a significant contributor to the global oral disease burden.The clear link

between oral diseases and tobacco use provides an ideal opportunity for oral

health professionals to become involved in tobacco control initiatives, including

smoking cessation programmes.

In Chapter 2 World Health Organization’s Tobacco Free Initiative (WHO TFI)

illustrates its role and the role of health professionals in tobacco control. The

approach of the WHO Oral Health Programme is detailed and policy approaches

are highlighted.

Chapter 3 suggests that urgent and concerted action is required to reduce the

disease, suffering and premature death which directly results from tobacco use.The

dental team has a significant role to play in tobacco control initiatives.A guideline

that provides clear advice for oral health professionals to become involved in

smoking cessation programmes is detailed. Oral health professionals can easily

incorporate this model into their daily clinical practice by following a simple step-

wise approach. Barriers for the limited involvement of oral health professionals in

tobacco cessation programmes are identified and ways to address these barriers

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are presented. Practical tips about setting up the dental office in order to engage in

clinical tobacco interventions are also illustrated.

Chapter 4 discusses how and why advocacy should be part of all oral health

professionals’ toolkit.The role of oral health professional associations is emphasised

and it is suggested that the first step to shape the organization’s own policies.The

FDI Statement on Tobacco in Daily Practice is illustrated, as is a Code of Practice

in Tobacco Control. A number of country case studies are provided including

testimonies from Kenya, Germany, India, South Africa, Sweden and Fiji.

Chapter 5 proposes recommendations to oral health organisations at the global,

national, and local levels.There is an urgent need to put tobacco control initiatives,

including cessation programmes, on the oral health agenda. The World Health

Organization and FDI World Dental Federation are providing the leadership and

support for this action.

“”

All health professionals -individually and through their

professional associations -have a prominent role to play in tobacco control.

Health professionals have the trust of the population, the

media and opinion leaders,and their voices are heard

across a vast range of social,economic and political arenas

PreambleJudith Mackay

The first cultivation of tobacco is thought to have been around 6000 BC, with

earliest reports of use amongst indigenous Americans around the first century BC.

By the 16th century it was being used worldwide.With 1.3 billion current tobacco

users in the world predicted to rise to 1.6 billion by 2030, this is not an epidemic

that is going to go away in the lifetime of present readers of this preamble.

There was no shortage of early warnings on the harmfulness of tobacco on dental

health. For example, Dr Joel Shew wrote in 1849 in a book entitled Tobacco: Its

History, Nature, and Effects on the Body and Mind (1).

"The pernicious effects of tobacco on the teeth are easily proved … the teeth of

tobacco chewers, who have continued the practice for a considerable length of

time, are generally bad, as any one may observe. It was once said in the presence of

clergyman of our acquaintance, that tobacco was good for preserving the teeth,

upon which he answered, 'That is not true, for on one side my teeth are perfectly

good, while on the other side, the one in which I have always kept my cud, there is

not a stump left.'"

A PubMed online search in May 2005 for "tobacco" and "oral" yields over 2,500

published articles in medical journals, but 150 years ago Dr Shew identified most of

the oral health effects of tobacco as we know them today - on the teeth, gums,

throat, taste, voice, and including cancer, albeit much of his evidence was anecdotal.

He also identified the struggle to quit tobacco use: "I have known some well-

meaning, pious people brought into the habit, and when once it is fixed upon them,

not one of a hundred has the power to leave it off." He thus identified the need for

primary prevention.

The FDI combines a summary of the health effects with suggested action in the

following statement on its website: "The effects of tobacco use on the population’s

oral health are alarming.The most significant effects of smoking on the oral cavity

are: oral cancers and pre-cancers, increased severity and extent of periodontal

diseases, as well as poor wound healing.The clear link between oral diseases and

tobacco use provides an ideal opportunity for oral health professionals to partake

in tobacco control initiatives and cessation programmes.8

Judith MackayDirector,

Asian Consultancy on Tobacco Control,

Senior Policy AdvisorWHO

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Dental professionals might well study Sun Tzu's "Art of War", written in the 6th

century B.C., because this classic work on military strategy, tactics, logistics and

espionage has great relevance to today's tobacco war. The objectives of reducing

tobacco are similar to those of all wars:

• To protect countries from being invaded and overpowered (eg by the

transnational tobacco companies)

• To save people from being killed

• To return land to growing food

• To improve the economy

• To protect the environment

Many dental professionals will focus on saving people from being killed, and from ill

health, by offering individual advice to patients. It may seem a leap away from clinical

practice for you to challenge the tobacco industry, examine alternative crops,

engage in economic surveys to show that tobacco is a debit to the economy,

support tobacco tax increases, protect the environment by supporting smoke-free

areas, or lobby governments to ratify and implement WHO’s first international

treaty – the Framework Convention on Tobacco Control.

Both approaches are vital and complementary, and the FDI has a long history of

supporting measures that will lead to reduced tobacco use in communities.And, in

addition, dentists themselves can be role models – by being non-smokers.

Dr Judith Mackay, FRCP (Edin) / FRCP (Lon), is a public health consultant for severalinternational organisations. She has lived in Hong Kong since 1967, and has conducted health-related missions in over 35 mostly developing countries worldwide.

Dr Judith Mackay is a British medical doctor and Senior Policy Advisor to the World HealthOrganization. She is based in Hong Kong where she is the Director of the Asian Consultancyon Tobacco Control. After an early career as a hospital physician, she became a healthadvocate. Her particular interests are tobacco use among women, and in developing countries.She is a Fellow of the Royal Colleges of Physicians of Edinburgh and London, and holdsprofessorships at the Chinese Academy of Preventive Medicine, Beijing, China and theDepartment of Community Medicine, University of Hong Kong. She has delivered 360conference papers world wide on varied aspects of tobacco control and other topics of publichealth. In addition to 160 academic papers and several books or chapters of books, she is theauthor of several atlases: “The State of Health Atlas,” “The Atlas of Human Sexual Behaviour,”‘The Tobacco Atlas’ and “The Atlas of Heart Disease and Stroke” and is currently working on“The Cancer Atlas.”

Dr Mackay has received many international awards including the WHO CommemorativeMedal, the Fries Prize for Improving Health, the Luther Terry Award for Outstanding IndividualLeadership, the International Partnering for World Health Award, the US Surgeon General’sMedallion, a royal award from the King of Thailand, and the Founding InternationalAchievement Award from the Asia Pacific Association for the Control of Tobacco. She regardsit as a great compliment to have been identified by the tobacco industry as one of the threemost dangerous people in the world."

ForewordsHR Yoon and JT Barnard, FDI

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HR Yoon,President,

FDI World Dental Federation

JT Barnard,Executive Director,

FDI World Dental Federation

Tobacco use is one of the major challenges to international health and all healthprofessionals have an important part to play in helping to stop the global tobaccoepidemic. The FDI has for a long time advocated for a close involvement of thedental team in such activities and we are very pleased to note the changes anddevelopments in many countries.

However, much remains to be done and the urgently needed changes arechallenging the traditional role models of dentists and other team members.Theyalso challenge the role of professional organisations and their involvement inpolitical decision processes.

This publication, jointly developed by the FDI and the World Health OrganizationOral Health Programme, provides the platform for greater dental commitment intobacco control initiatives, including advocacy and smoking cessation programmes.

Oral health care teams acknowledge that helping tobacco users to quit the habit ispart of their role and it is now formally recognised that smoking cessation is partof the practice of dentistry. In addition, oral health professional organisations havea responsibility in supporting political processes that lead to an environmentconducive to health and that includes strong tobacco control policies.

The FDI welcomes and fully supports the WHO Framework Convention onTobacco Control (FCTC) as part of the political and legal activities needed toeffectively address the tobacco issues. It is one of our tasks as a non-governmentalhealth organisation in official relations with WHO to promote WHO policies andto collaborate on issues of common interest.We highly welcome the initiative ofWHO to dedicate World No Tobacco Day 2005 to the important role of healthprofessional organisations in tobacco control that was initiated through aworkshop that the FDI and the World Medical Association organised during the12th World Conference Tobacco or Health in 2003 in Finland.

We sincerely hope that this guide for dentists and oral health organisations will behelpful in increasing awareness and in facilitating tangible engagement in tobaccocontrol on the individual patient level as well as in the broader political context.TheFDI is prepared to assist and support this process wherever possible.

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Unhealthy lifestyles such as smoking and other tobacco use are among theimportant risk factors for many chronic diseases, including several oral diseases andconditions. Globally, the risk factors approach is recommended being the leadingprinciple in public health work since the Ottawa Charter for Health Promotion wasadopted in 1986. The charter identified five health promotion action areas formodern public health:

(1) build healthy public policy;

(2) create supportive environments;

(3) develop personal skills;

(4) strengthen community action, and

(5) reorient health services towards prevention and health promotion.

The WHO Framework Convention for Tobacco Control (WHO FCTC) is a major newplatform for building health policies and creating oral health supporting environments.WHO FCTC provides an important context for ensuring policies for oral healththrough tobacco control becomes an integral part of national health programmes,emphasising the inter-relationship between oral health and general health.

Reorientation of oral health services towards prevention and health promotionmay contribute significantly to the development of personal skills of patients andlikewise oral health professionals can be most instrumental in community-basedpublic health programmes oriented towards tobacco cessation.

Tobacco prevention starts with developing healthy lifestyles among children andyouth. The WHO Oral Health Programme has designed a model for including oralhealth promotion within the framework of the Health Promoting Schools, and thisinitiative also gives emphasis to tobacco and oral health. Oral health professionalshave an important role to play in the implementation of school oral healthprogrammes worldwide and the challenges including tobacco prevention are highparticularly in countries with growing tobacco consumption.

On the basis of the WHO No Tobacco Day 2005, the WHO and FDI have embarkedon tobacco control with the intention of preventing tobacco-related oral diseaseand promoting health and wellbeing. The "Tobacco or Oral Health - an advocacyguide for oral health professionals" is a most valuable tool in our joint work forbetter health for all. Combined efforts on tobacco control by the networks of oralhealth professionals, public health administrators and policy makers at local,national and international levels may guarantee success in disease prevention andhopefully this manual may stimulate the sharing of experiences.

I sincerely hope that this advocacy guide will be helpful in increasing tobaccoprevention activities on the individual patient level and increasing awareness oftobacco and oral health within the community and at political level.

Poul Erik Petersen, WHO

Poul Erik Petersen,Chief,Global Oral Health Programme,WHO Geneva

“ ”Every 6.5 seconds one tobacco user

dies from a tobacco-related

disease somewhere in the world

1 Introduction:The Extent of the Problem

13

...Tobacco isthe secondmajor cause of death in the world...

Basic Facts About Tobacco

Carmen Audera-Lopez

Currently, there are an estimated 1.3 billion smokers in the world.The total global

prevalence in smoking is 29% (47.5% of men and 10.3% of women over 15 years of

age smoke). Of the 1.3 billion smokers, more than 900 million live in developing

countries (2).

Tobacco is the second major cause of death in the world. It is currently responsible

for the death of one in ten adults worldwide. Every 6.5 seconds one tobacco user

dies from a tobacco-related disease somewhere in the world (2). Cigarettes kill half

of all lifetime users and half of those die in middle age (35-69 years), losing an

average of 20 to 25 years of life (3).

The death toll from tobacco consumption is now 4.9 million people a year; if

present consumption patterns continue, the number of deaths will increase to 10

million by the year 2020, 70% of which will occur in developing countries (4).With

current smoking patterns, approximately 500 million people alive today will

eventually be killed by tobacco use. By 2030, tobacco is expected to be the single

biggest cause of death worldwide, accounting for about 10 million deaths per year.

As research on the effects of tobacco on health continues and the number of

affected people increases, the list of conditions caused by tobacco has expanded.

There is nowadays evidence that almost every organ in the body is affected by

tobacco consumption and now it also includes cataracts, pneumonia, acute myeloid

leukemia, abdominal aortic aneurysm, stomach cancer, pancreatic cancer, cervical

cancer, kidney cancer, and periodontitis. These diseases add on to the already

known such as lung, oesophagus, larynx, mouth and throat cancer, chronic

pulmonary and cardiovascular diseases, as well as negative effects on the

reproductive system and sudden infant death syndrome (5).

Non-smokers also suffer the health consequences of tobacco.There is conclusive

scientific evidence that shows that involuntary exposure to tobacco smoke puts

non-smokers at a greater risk of lung cancer, respiratory and cardiovascular

diseases, and increases the risk of asthma, respiratory conditions, ear infections and

sudden infant death syndrome in infants (6).

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The costs of tobacco go far beyond the tragic health consequences.Tobacco is also

a significant economic burden on families and societies and is a major threat to

sustainable and equitable development (7).

Despite the current knowledge of the harm caused by tobacco, consumption

continues to increase. The tobacco epidemic is shifting from industrialized to

developing countries (Figure1).There are two main reasons for this phenomenon.

Firstly, nicotine is extremely addictive so it is very difficult to quit tobacco

consumption in spite of the willingness of many tobacco consumers to quit. The

other main reason is the marketing strategies of the tobacco industry.The tobacco

industry needs to replace consumers that die prematurely or who succeed in

quitting consumption. The industry uses all kinds of strategies to create new

markets, targeting those that do not consume tobacco yet, such as young people

and men and women in developing countries.

Figure 1. Current and future estimates of number of smokers in the world

Source: Guindon GE & Boisclair D. Past, Current and future Trends in Tobacco Use. HNP DiscussionPaper No.6, Economics of Tobacco Control Paper No. 6.WHO and The World Bank, 2003.

Recent findings of the Global Youth Tobacco Survey (GYTS), the largest global

survey on adolescents aged 13 to 15 and tobacco, show that, although young

people’s use of cigarettes and other tobacco products varied dramatically by site,

young girls are smoking almost as much as young boys and that girls and boys are

using non-cigarette tobacco products such as spit tobacco, bidis, and water pipes at

similar rates. These findings suggest that projections of future tobacco-related

deaths world wide might be underestimated because they are based on current

patterns of tobacco use among adults, where women are only about one-fourth as

likely as men to smoke cigarettes (8). Nearly 24% of all young smokers started by

the age of ten, when they are far too young to understand or resist social

expectations (9).

1,600,000

1,400,000

1,200,000

1,000,000

800,000

600,000

400,000

200,000

2000 2010 2020 2025

Num

ber

of s

mok

ers

(in t

hous

ands

)

Developed

Developing

Transition

15

Basic Facts About Tobacco and Oral Health

Rob H Beaglehole

The effects of tobacco use on the population’s general health have been well

illustrated. However, the effects of tobacco on oral health are also important to

take into consideration.The most significant effects of smoking on the oral cavity

are oral cancers and pre-cancers, increased severity and extent of periodontal

diseases, and poor wound healing.

Tobacco use and its association with oral diseases is a major contributor to the

global oral disease burden, responsible for up to half of all periodontitis cases

among adults (10).The clear link between oral diseases and tobacco use provides

an ideal opportunity for oral health professionals to take part in tobacco control

and cessation programmes. Some of the most common diseases and problems are

described in the table below.

Table 1:Tobacco induced and associated conditions (11)

Oral cancer

Leukoplakia – lesions which are potentially malignant:

• Nodular leukoplakia

• Verrucous leukoplakia

• Speckled leukoplakia

• Erythroplakia

Oral mucosal conditions:

• Smoker’s palate

• Smoker’s melanosis

Tobacco associated effects on the teeth and supporting tissues:

• Periodontal diseases

• Premature tooth loss

• Acute Necrotising Ulcerative Gingivitis

• Staining

• Halitosis

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Oral mucosal diseases

Smoking is associated with several changes in the oral mucous membrane and has

a direct carcinogenic effect on the epithelial cells of the oral mucous membranes.

Indeed, smoking is the major risk factor of developing oral cancer (12).The most

common type of oral cancer is squamous-cell carcinoma, which includes about 90%

of oral malignancies (13).

Amongst men, oral cancer is the eighth most common cancer worldwide.

Incidence rates of oral cancer are high in developing countries, particularly in some

areas of South Central Asia where it is among the three most prevalent types of

cancer (12). Leukoplakia, which is the most common of the potentially malignant

lesions of the oral mucous membranes, occurs approximately six times more

frequently in smokers than in non-smokers.

Smoker’s palate, smoker’s melanosis, and oral candidosis all occur more frequently

in smokers than in non-smokers (14).

Periodontal diseases

A clear association between tobacco use and the prevalence and severity of

periodontal disease exists (15). Periodontal bone loss, periodontal attachment loss,

as well as periodontal pocket formation are all associated with tobacco use.

Numerous studies also indicate that smoking adversely affects the outcome of

periodontal therapy. Smokers have been reported to show poorer success rates in

periodontal therapy in comparison to non-smokers (16).

"Smoker's palate (formerly callednicotinic stomatitis of palate) in aheavily smoking farmer of NorthernThailand (see also the black stains onteeth)

�

�

Non-homogeneous leukoplakia of the lateral border of tongue(speckled leukoplakia).Transformation of this type ofleukoplakia is very likely.

Photos courtesy of Prof Peter Reichart, Berlin

Evidence also suggests that a dose-response relationship exists between smoking

and periodontal health (17).

Wound healing

Tobacco is a peripheral vasoconstrictor that influences the rate at which wounds heal

within the mouth. Thus, healing among smokers is slower and not as successful

following oral surgery. The resulting absence of blood clotting that follows the

removal of teeth occurs four times more frequently in smokers than in non-smokers.

In addition, smoking has an adverse effect upon the healing of extraction wounds (18).

Dental implants

An abundance of evidence exists to suggest that smoking is detrimental to both the

initial and long-term success of dental implants, and that smoking cessation can be

beneficial in improving implant success rates (14). In one study, the most significant

factor predisposing to implant failure was smoking. Smokers had more than twice

the failure rate in comparison to non-smokers (19).

Smell and taste

Smoking has been shown to affect both taste

and smell acuity. Tobacco, whether chewed

or smoked, can cause halitosis (14).

Aesthetics

Tobacco stains can penetrate into

enamel, dental restorations and

dentures creating unsightly brown to

yellow darkening of teeth. Halitosis

and tooth staining, which are both

visible and reversible, have been

shown to be common concerns of

smokers and can be used as motivations

for quitting (20).

17

2. The World HealthOrganization andTobacco Control

18

Tobacco Free Initiative

Annemieke Brands

The WHO Tobacco Free Initiative (TFI) was established in 1998 to focus

international attention, resources and action on the global tobacco epidemic.

TFI's objective is to reduce the global burden of disease and death caused by

tobacco, thereby protecting present and future generations from the devastating

health, social, environmental and economic consequences of tobacco consumption

and exposure to tobacco smoke.To accomplish its mission,TFI:

• Provides global policy leadership;

• Encourages mobilization at all levels of society; and

• Promotes the WHO Framework Convention on Tobacco Control (WHO

FCTC), encourages countries to adhere to its principles, and supports them in

their efforts to implement tobacco control measures based on its provisions.

According to the WHO, effective tobacco control interventions do not only focus

on changing the behaviour of individual tobacco consumers. Instead, they take a

broader and more comprehensive approach targeting the environment and

promoting social norm change. A comprehensive mix of measures is required to

efficiently and effectively prevent and control the use of tobacco, protect non-

smokers from the exposure to tobacco smoke, and, regulate tobacco products.

Experience has shown that there are many cost-effective tobacco control measures

that can be used in different settings and that can have a significant impact on

tobacco consumption. The most cost-effective strategies are population-wide

policies, such as bans on direct and indirect tobacco advertising, tobacco tax and

price measures, smoke-free environments in all public and workplaces, and large

clear graphic health messages on tobacco packaging. All these measures - both

demand and supply side measures - are included in the provisions of the WHO

Framework Convention on Tobacco Control (WHO FCTC).

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The WHO Framework Convention on Tobacco Control(FCTC)

The WHO FCTC is an international legal instrument designed to control the global

tobacco epidemic. It is the first public health treaty negotiated under the auspices

of the WHO. After nearly four years of negotiations, the text of the treaty was

agreed upon on 1 March 2003.The World Health Assembly unanimously adopted it

on 21 May 2003. On 29 November 2004, 40 countries had deposited their

instrument of ratification or legal equivalent - the number of contracting parties

required for the Convention to enter into force 90 days later. Since 29 November

2004, many more countries have ratified (63 Countries on 19 April 2005), making

it one of the most rapidly embraced UN treaties in history.

The WHO FCTC and related protocol approach is a dynamic model of global

standard setting.The term 'framework convention' is used to describe a variety of

legal agreements that establish broad commitments and a general system of

governance for a particular issue. With the WHO FCTC in place, national public

health policies, tailored around national needs, can be advanced without the risk of

being undone by transnational phenomena (e.g. smuggling as well as cross-border

advertising, promotion and sponsorship).

The Preamble of the WHO FCTC specifically mentions the role of health professionals

in tobacco control. Article 12 on 'Education, communication, training and public

awareness' and Article 14 on 'Demand reduction measures concerning tobacco

dependence and cessation' are also of particular interest for health professionals.

PREAMBLE OF THE WHO FCTC

"…Emphasizing the special contribution of nongovernmental organisations

and other members of civil society not affiliated with the tobacco industry,

including health professional bodies, women’s, youth, environmental and

consumer groups, and academic and health-care institutions, to tobacco

control efforts nationally and internationally and the vital importance of their

participation in national and international tobacco control efforts…"

Tobacco control efforts are more likely to be sustained when incorporated into

existing national, state and district level health structures and linked with existing

positions and accountability processes. Involvement of the governmental health

sector is expected to increase awareness among health personnel and contribute

to developing sustainable tobacco control programmes at the country level. Such a

systematic approach will also pave the way for multisectoral acceptance of tobacco

control efforts in countries.

20

"The WHO FCTC negotiations have already unleashed a process that has

resulted in visible differences at country level.The success of the WHO FCTC

as a tool for public health will depend on the energy and political commitment

that we devote to implementing it in countries in the coming years. A

successful result will be global public health gains for all."

Dr Jong-Wook Lee, Director-General,World Health Organization

The Role of Health Professionals in Tobacco Control

All health professionals - individually and through their professional associations -

have a prominent role to play in tobacco control. Health professionals have the

trust of the population, the media and opinion leaders, and their voices are heard

across a vast range of social, economic and political arenas.

At the individual level, health professionals should be tobacco-free role models.

They should help tobacco users overcome their addiction and educate the

population on the harm of tobacco use and exposure to second-hand smoke.

At the community/local level, health professionals can be initiators or supporters

of some of the policy measures described above, by engaging, for example, in efforts

to: promote smoke-free workplaces and smoke-free public transport; persuade

local governments to ban tobacco advertising and promotion; to make sports

21

events tobacco-free; and, to extend the availability of tobacco cessation resources.

Campaigns may also be needed to increase compliance with existing laws, such as

a ban on sales to minors. Health professionals may further organize a special day to

encourage and assist people to quit tobacco, and visit schools to discuss the impact

of tobacco and industry tactics with students, staff and even with parents. Health

professionals may regularly contribute to health related columns in local

newspapers and/or by appearing on the local radio and television.

At the national and international levels,health professionals and their organisations can

add their voice and their weight to national and global tobacco control efforts like tax

increase campaigns and become involved at the national level in promoting the WHO

FCTC and the development of a national plan of action for tobacco control.

In addition, health professional organisations can show leadership and become role

models for other professional organisations and society by embracing the tenants

of the Health Professional Code of Practice on Tobacco Control.

Health professional organisations are responsible for action within and outside

their organisations.Within their organisations, they should raise awareness about

tobacco among their individual members. If awareness is already high, new scientific

research findings, new developments in cessation, and new policy developments

could be shared. If awareness is low, health professional associations could highlight

the available scientific evidence, the politics and economics of tobacco, and the way

tobacco promotion works in a more through and wide-ranging effort. Among the

membership, health professional organisations could:

• Carry out regular surveys of health professional tobacco consumption habits

and attitudes towards tobacco consumption;

• Disseminate the results among the members;

• Set up a tobacco control group within the professional association;

• Educate members about tobacco;

• Make the premises and meetings smoke- and tobacco-free;

• Brief health journalists on tobacco related issues and encourage regular inclusion

of news stories and features about tobacco in the health professional press;

• Keep the members up to date and trained on cessation methods; raise the

issue of litigation and establish links with those pursuing legal action;

• Review investment portfolios of their organisations to eliminate tobacco holdings;

• Refuse tobacco company representatives' donations for events or congresses

or their participation as presenters or speakers because their intention is to

confound the audience through their good-will speech and raise doubts about

scientific research on tobacco risks and harms; and

…showleadership and become rolemodels…

22

• Maintain awareness of any tobacco company strategy to try to influence their

institution or to take part in any scientific initiative, thus protecting their

association or society from tobacco industry influence.

Outside their own organisation and membership, health professional organisations

could:

• Contribute to the formulation of national plans of action for tobacco control;

• Work with other health professional organisations to develop a common

position on tobacco control and consider establishing a coalition;

• Use the news media and work with politicians to make them feel that it is in

their interest to accept invitations to meetings and other events that focus on

tobacco control issues;

• Campaign for smoke-free/tobacco-free health care facilities to make non-

smoking the norm;

• Influence the content of health professional education and motivate students

by setting up a tobacco control body;

• Carry out surveys and prepare regular reports on tobacco related issues

highlighting tobacco control priorities; and

• Lobby for public and private reimbursement for cessation counselling.

Health professionals can intervene in all of these areas. They reach a high

percentage of the population. Health professionals have the opportunity to help

people change their behaviour and they can give advice, guidance and answers to

questions related to the consequences of tobacco use, they can help patients to

stop smoking. Studies have shown that even brief counselling by health

professionals on the dangers of smoking and the importance of quitting is one of

the most cost-effective methods of reducing smoking.

Medical doctors have paved the way in a number of countries, including the UK

where the Royal College of Physicians were responsible for the groundbreaking

report in 1962, which acknowledged that smoking causes cancer.They later helped

established and provided early financial support to ASH (Action on Smoking and

Health), the tobacco control advocacy non governmental organisation (NGO).

According to Doctors and Tobacco: Medicines Big Challenge, health professionals

probably have "the greatest potential of any group in society to promote a

reduction in tobacco use, and thus, in due course, a reduction in tobacco-

induced mortality and morbidity".

David Simpson (21)

23

...Tobacco use is acommon riskfactor toseveral chronicand oraldiseases...

Approach of the Oral Health Programme, WHO

Poul Erik Petersen,WHO

The Tobacco Epidemic

The epidemic of tobacco use is one of the greatest threats to global health today.

Approximately one-third of the adult population in the world use tobacco in some

form and of whom half will die prematurely. This huge death toll is rising rapidly,

especially in low-income and middle-income countries where most of the world’s

1.3 billion tobacco users live. Developing countries already account for half of all

deaths attributable to tobacco (22).This proportion will rise to 7 out of 10 by 2025

because smoking prevalence has been increasing in many low- and middle- income

countries even though it is decreasing in high-income countries.

Worldwide the prevalence of tobacco use is highest amongst people of low

educational background and among the poor and marginalised. In

several developing countries there have been sharp increases in

tobacco use especially among men. As the tobacco industry

continues to target youth and women there are also concerns

about rising prevalence rates in these groups. The shift in

the global pattern of tobacco use is reflected in the

changing burden of disease and tobacco deaths. Sadly,

the future appears worse. Because of the long time

lapse between the onset of tobacco use and the

inevitable wave of disease and deaths that

follow, the full effect of today’s globalisation of

tobacco marketing and increasing rates

of usage in the developing world will be

felt for decades to come.

Tobacco use is a common risk factor to several

general chronic diseases and oral diseases and the

negative impact relates not only to smoking but use of smokeless tobacco. Most

recently, the International Agency for Research on Cancer observed that there is

sufficient evidence that smokeless tobacco causes oral cancer and pancreatic

cancer in humans (23). Chewing tobacco is known as plug, loose leaf and twist. Pan

masala or betel quid consists of tobacco, areca nuts and staked lime wrapped in a

betel leaf.They can also contain other sweeteners and flavouring agents. Moist snuff

is taken orally while dry snuff is powdered tobacco that is mostly inhaled through

the nose. In comparison to smoking habits, the pattern of use of smokeless tobacco

is less documented, particularly in developing countries (24, 25).

24

Tobacco-induced oral disease

Tobacco-induced oral diseases contribute significantly to the global oral disease

burden (26, 27). Tobacco is a risk factor for oral cancer, oral cancer recurrence,

adult periodontal diseases, and congenital defects such as cleft lip and palate in

children whose mother smokes during pregnancy. Tobacco use suppresses the

immune system’s response to oral infection, retards healing following oral surgical

and accidental wounding, promotes periodontal degeneration in diabetics and

adversely affects the cardiovascular system. These risks increase when tobacco is

used in combination with alcohol or areca nut. Most oral consequences of tobacco

use impair quality of life be they as simple as halitosis, as complex as oral birth

defects, as common as periodontal disease or as troublesome as complications

during healing.

Oral and pharyngeal cancers pose a special challenge to oral health programmes

particularly in developing countries. Cancer of the oral cavity is high among men,

where oral cancer is the eighth most common cancer in the world (Figure 2) (28).

Incidence rates of oral cancer are high in developing countries, particularly in areas

of South Central Asia where cancer of the oral cavity is among the three most

frequent types of cancer. Meanwhile, dramatic increases in incidence rates of

oral/pharyngeal cancers have been reported in countries or regions such as

Germany, Denmark, France, Scotland, Central and Eastern Europe, and rates are on

the increase in Japan, Australia,New Zealand and in the USA among non-whites (28).

Figure 2. Comparison of the most common cancers in more or less developed countries in 2000 (28)

Number thousands

0 250 500

Brain, etc.

Other pharynx

Pancreas

Kidney

Larynx

Leukaemia

Non-Hodgkin Lymphoma

Oral cavity

Bladder

Oesophagus

Liver

Colorectal

Prostate

Stomach

Lung

Less developed

More developed

Male

“”

The FDI vigorously supports allmeasures that endeavour to

prevent the initiation of tobaccouse by young people and

dissuade initiation by adults

26

National cancer control programmes

The WHO’s approach to chronic disease prevention places emphasis on the rising

impact of tobacco-related diseases in low-income and middle-income countries and

the disproportionate suffering it causes in poor and disadvantaged populations.The

WHO has initiated a number of public health actions. In 2002, the WHO stimulated

the process for promoting and reinforcing the development of national cancer

control programmes as the best known strategy to address the cancer problem

worldwide (29).This initiative also includes prevention of oral cancer. In addition to

strong comprehensive tobacco control measures, dietary modification is another

approach to cancer control. A national cancer control programme is a public health

programme designed to reduce cancer incidence and mortality and improve quality

of life of cancer patients, through the systematic and equitable implementation of

evidence-based strategies for prevention, early detection, diagnosis, treatment and

palliation, making the best use of available resources. Thus, conducting a cancer

prevention programme, within the context of an integrated non communicable

disease prevention programme, is an effective national strategy. Tobacco use,

alcohol, nutrition, physical activity and obesity are risk factors common to other

non communicable diseases such as cardiovascular disease, diabetes and

respiratory diseases. As emphasised by the World Health Report 2002 (22) on

reducing risks and promoting healthy life, chronic disease prevention programmes

can efficiently use the same health promotion mechanisms.

27

WHO Framework Convention for Tobacco Controland Oral Health

At the World Health Assembly in May 2003 the Member States agreed on a

groundbreaking public health treaty to control tobacco supply and consumption.

The text of the WHO Framework Convention on Tobacco Control (FCTC) covers

tobacco taxation, smoking prevention and treatment, illicit trade, advertising,

sponsorship and promotion, and product regulation (30).The convention is a real

milestone in the history of global public health and in international collaboration. It

means nations will be working systematically together to protect the lives of

present and future generations, and take on shared responsibilities to make this

world a better and healthier place.

As emphasized in the World Oral Health Report 2003 (31), there are several

ethical, moral and practical reasons why oral health professionals should strengthen

their contributions to tobacco-cessation programmes, for example:

• They are especially concerned about the adverse effects in the oropharyngeal

area of the body that are caused by tobacco practices;

• They typically have access to children, youths and their caregivers, thus

providing opportunities to influence individuals to avoid all together, postpone

initiation or quit using tobacco before they become strongly dependent;

• They often have more time with patients than many other clinicians, providing

opportunities to integrate education and intervention methods into practice;

• They often treat women of childbearing age, thus are able to inform suchpatients about the potential harm to their babies from tobacco use;

• They are as effectiveas other clinicians inhelping tobacco usersquit and results are improved whenmore than onediscipline assistsindividuals during thequitting process; and

• They can build theirpatient’s interest indiscontinuing tobaccouse by showing actualtobacco effects in the mouth.

28

...Children and youth areimportanttarget groupsin tobaccoprevention...

Oral health professionals and dental associations worldwide should consider this

platform for their future work and design national projects jointly with health

authorities.Tobacco prevention activities can be translated through existing oral health

services or new community programmes targeted at different population groups.

Children and youth are important target groups in tobacco prevention.The Health

Promoting School provides an effective setting for tobacco prevention and the

WHO Oral Health Programme has developed a manual for implementation of oral

health promotion through schools (32). Guidelines are given for organisation of

tobacco prevention activities based on healthy environments and health education.

Tobacco control and the WHO Global Oral Health Programme

The WHO Global Oral Health Programme aims to control tobacco-related oral

diseases and adverse conditions through several strategies (31).Within the WHO,

the Oral Health Programme forms part of the WHO tobacco-free initiatives, with

fully integrated oral health related programmes. Externally, the Oral Health

Programme encourages the adoption and use of WHO tobacco cessation and

control policies by international and national oral health organisations. Primary

partners are NGOs who are in official relations with the WHO, i.e. the FDI World

Dental Federation and the International Association for Dental Research (IADR).

World Health Assembly 2003 where the WHO FCTC was approved by the Ministers of Health

The priority areas in relation to tobacco control given by the WHO Global Oral

Health Programme are outlined in Table 2. Firstly, state-of-the-science analysis and

development of modern, integrated information systems will provide an important

new platform for public health initiatives in tobacco control. Secondly, the Programme

provides assistance to countries in risk behaviour analysis and surveillance in order

to help countries include oral health aspects in tobacco prevention programmes.

Thirdly, the WHO Oral Health Programme supports the translation of knowledge

into action, e.g. tobacco prevention activities in schools or by involving oral health

professionals in national or community-based tobacco control.

Fourthly, the WHO Oral Health Programme has intensified the work towards

development of surveillance, monitoring and evaluation systems. Operational

research may provide for outcome and process evaluation of community approaches

for tobacco control and such research may then help sharing experiences across

countries (33). In particular, emphasis is given by the WHO Oral Health Programme

to development of national tobacco programmes in low-income and middle-income

countries. Worldwide, strong networks and effective collaboration may facilitate

activities with NGOs such as the FDI World Dental Federation.

The WHO Oral Health Programme continues strengthening work for tobacco

control, particularly through encouraging and supporting countries to incorporate

oral health in their tobacco prevention policies. Evaluation and sharing experiences

from tobacco cessation programmes are important

for such global initiatives and the WHO

Oral Health Programme appreciates

the expanded collaboration with

the oral health community in

this activity. This joint

WHO/FDI Tobacco

Control Advocacy

Guide, which is to be

launched on World

No Tobacco Day

2005, provides a

c o n s t r u c t i v e

platform for tobacco

control programmes

in the future.

29

30

State-of-the-scienceand new knowledge

Assistance tocountries in riskbehaviour analysisand risk surveillance

Translation ofknowledge intoaction programmesin countries/communities

Evaluation,monitoring andsurveillance

• Analysis of existing knowledge about oral health –general health and relationships to tobacco use

• Update of the WHO Global Oral Health DataBank, including periodontal disease data (CPI) anddata on oral cancer

• Integration of oral health data bank into otherWHO databanks on chronic disease, common riskfactors and tobacco use

• Update of the WHO Oral Health Surveys BasicMethods, including guidelines for recording riskfactors/tobacco use and tobacco-induced oraldiseases and conditions

• Development of indicators and tools forassessment of tobacco use and their impact onoral health, as part of national health programmes

• Tests of instruments in selected countries

• Analysis of policy in relation to tobacco use andoral health

• Effective use of schools in tobacco preventionamong children and adolescents, based on HealthPromoting Schools principles

• Guidelines on tobacco prevention and oral healthfor pregnant women and young mothers

• Effective involvement of oral health professionalsin tobacco cessation programmes – analysis ofbarriers and constraints

• Operational research in tobacco behaviourmodification

• Development of community/country specific goalsfor tobacco prevention, incorporating oral health

• Development of models for evaluation ofcommunity-based oral health promotionprogrammes, including tobacco control

• Outcome and process evaluation of communitydemonstration projects for sharing experiences

• Development of tools for surveillance andmonitoring tobacco control programmes

Table 2. WHO Oral Health Programme objectives and activities carried out inrelation to tobacco control

3. The Dentist andTobacco Control

31

Rob H Beaglehole

Urgent and concerted action is required in order to reduce the disease, suffering

and premature death which directly results from tobacco use. The WHO

Framework Convention on Tobacco Control (WHO FCTC) highlights the impact

tobacco control programmes can have on reducing this burden. These measures

include tobacco cessation programmes. The WHO recently acknowledged the

importance of integrating tobacco control programmes into health systems (34).

Dental professionals have been identified as having a significant role to play in

supporting smokers who indicate a desire to quit.A decline in tobacco use would

improve both general and oral health, and would also help to reduce widening

inequalities across populations.

All health providers must be involved (in treatment of tobacco dependence),

including oral health professionals who, in many countries, reach a large

proportion of the healthy population.

The World Health Report 2003 (34)

The dental team has a major role to play in smoking prevention. Evidence suggests

that smoking cessation interventions are both effective (35) and cost-effective (36).

A brief intervention will often result in significant health gain and, in the long term,

reduce smoking-related health-care costs to countries. Unfortunately, advice on

quitting smoking is still not a routine part of clinical practice for many oral health

professionals. Nor are many National Dental Associations (NDAs) involved in

tobacco control (37). This document encourages both clinicians and oral health

professionals to scale up their involvement in tobacco control activities, including

advocacy and smoking cessation programmes.

The involvement of oral health professionals in smoking cessation will help

contribute to wider tobacco control strategies. Changing patient expectations

means there is less likelihood of a defensive reaction to questions about smoking.

Strong evidence to support the introduction of this activity in primary dental care

now exists. Providing help for those patients wishing to quit can offer substantial

32

...Oral healthprofessionalsare in auniqueposition tocontribute to tobaccocontrol...

oral and general health benefits. The time is right to ensure that what is known

about tobacco control is translated into action and becomes routine in the job of

the dental team.

The dental profession has an important role to play in combating the tobacco

epidemic. Apart from supporting wider tobacco control measures, oral health

professionals can help patients to stop using tobacco.This may be the single most

important service dentists can provide for their patients’ overall health (38).

Getting Oral HealthP r o f e s s i o n a l sInvolved

Oral health professionals are in

a unique position to contribute

to tobacco control in a number

of complementary ways: as role

models by not smoking; in

counselling patients not to

smoke; in referring patients to

smoking cessation services; in

speaking out publicly; and

lobbying for comprehensive public policies to control tobacco use (39). National

Dental Associations and oral health organisations are also ideally placed to mobilise

other health care professionals, such as doctors, nurses and pharmacists, to become

involved in tobacco control initiatives.

In many countries dentists have higher smoking rates than the general population,

thereby acting as negative role models. Encouraging dentists to quit smoking can

greatly enhance tobacco control initiatives as they become more likely to engage in

tobacco control advocacy.They also act as positive role models for their patients.

It is important to target dental students by motivating and encouraging them

to become more engaged in tobacco control as they are the most open to a

new understanding of their professional responsibilities. It is also beneficial to target

deans of dental schools, professors teaching at universities and others who have

influence with oral health professionals, such as Ministries and Departments of Health,

Ministers of Health, senior public health officials and national dental councils

and boards.

It is imperative that oral health professionals recognise that their professional duty

33

extends beyond the treatment and cure of tobacco-caused disease to include

prevention and cessation.This lack of recognition is reinforced by health insurance

schemes that rarely pay for counselling or cessation services.

Smoking is linked to a number of oral health problems, as previously discussed.The

oral health effects of smoking can be a useful indicator and motivator for smokers

to quit, as these effects provide a visual and clear illustration of the damage smoking

has on the body.Very limited time is required to assist those smokers interested

and willing to stop. It has been shown that even a few minutes of advice to a patient

can be effective (40).

Dentists have regular contact with patients, are the first to see the effects of

tobacco in the mouth and are the only health professionals who frequently see

‘healthy’ patients. Dentists are thus in an ideal position to reinforce the anti-

tobacco message, as well as being able to motivate and support smokers willing

to quit (41).

How to Help Patients Stop

A number of evidence-based guidelines provide advice for oral health professionals

to become involved in smoking cessation programmes. One such guide that is

orientated at the dental team provides a clear and

effective way forward for oral

health professionals to

become engaged in this

important and relevant area

of prevention (39).

The 4As Model

The 4As model is an example

of a method that is a straight-

forward and quick means of

identifying smokers who want

to quit and how best to help

them to be successful. Dentists

can easily incorporate this

model into their daily clinical

practice by following the step-

wise approach as illustrated

in Table 3.

Ask• All patients about their smoking status and record information in clinical notes

Advise• Advise all smokers to stop• Give clear, personalised advice• Highlight oral health effects of tobacco use• Emphasise reversible nature of oral health effects• Assess interest in attending smoking cessation clinic (if one exists)

34

ASK All patients should have their smoking status checked atregular intervals.

ADVISE All smokers should be advised on the value of quitting.ARRANGE Refer motivated smokers to the local Smoking Cessation

Service.ASSIST Support should be offered to those smokers who want to

stop, but are not prepared to be referred.

Helping smokers stop: the guide for the dental team (39)Permission to reprint kindly granted from the HDA (Health Development Agency)

Table 3:The 4As Model

Arrange• If interested refer to local smoking cessation clinic• Provide encouragement and information on services• Stress oral health benefits of quitting

Assist• If interested in quitting but not keen of attending clinic, provide support and encouragement to quit• Review past experiences of quitting• Set quit date• Identify preparation required• Encourage use of NRT and Zyban® as necessary• Assess progress at next appointment

Review• Re-assess smoking status at next recall appointment

35

36

…smokingcessationinterventionsrequire 3minutes orless of directclinical time...

The Team Approach

In order to achieve the greatest success in helping smoking patients quit the entire

team at the dental practice should be committed to smoking cessation. It is

important to stress the need for good communication between team members, the

need for regular meetings and access to training in smoking cessation advice.

It is essential that roles and responsibilities are delegated for each team member in

the practice. For example the practice manager can encourage effective

communication amongst the dental team and ensure a non-smoking practice policy,

the receptionist may be able to ask new patients about smoking status and provide

information on their local Smoking Cessation Service; and dentists and hygienists

can discuss the 4As approach.

Overcoming Barriers

Numerous barriers have been identified for the limited involvement of dental

professionals in tobacco cessation programmes.The most frequent barriers cited

are: the amount of time required for staff, lack of adequate reimbursement, and lack

of knowledge and skills (37).

Possible barriers to smoking cessation activities in the dental setting (42)

• Lack of time

• Lack of reimbursement mechanisms

• Lack of confidence and skills

• Concerns over effectiveness of support

• Lack of readily accessible patient education materials

• Expected patient resistance

However, these perceived barriers are not insurmountable. The following points

review how these barriers can be addressed.

Lack of time:

It has been recommended that brief smoking cessation clinical interventions

require 3 minutes or less of direct clinical time.The recommended protocol need

not take a great deal of clinical time for the dentist, especially if they work together

with other members of the team.

Lack of reimbursement mechanisms:

This is an issue that needs to be addressed. Recognition of the very limited clinical

time involved may provide some reassurance.

37

Lack of confidence and skills:

Confidence and skills can be built and developed with appropriate training. Many

health organisations now offer smoking cessation training courses for primary

health care professionals.These courses are tailored for different levels of activity.

Concerns over effectiveness of support:

Reviews of the evidence reveal that smoking cessation advice is one of the most

effective forms of health promotion support. By following the recommended

protocol advice given by the dental team can have a significant effect.

Lack of readily accessible patient education materials:

This Guide has been designed to inform and encourage the dental team to become

involved with smoking cessation initiatives for their patients. Many NDAs and

Ministries of Health provide other patient education and waiting room material.

Expected patient resistance:

Surveys of dental patients have revealed that many patients believe that dentists

should actively encourage smoking cessation (43).This is encouraging as it means

that patients actually expect their dentist to be concerned about their overall

health, including their smoking status.

Setting Up Your Practice for Clinical Tobacco Intervention

The dentist’s office is an ideal place to give people personalised messages about

their health, offer long-term follow-up, prescribe stop smoking medication (in some

countries), and offer supportive encouragement. Doing this may sometimes require

changes in clinical style, communication style, dental record system, appointment

system, and duties of staff members.

However, the rewards of delivering effective clinical tobacco intervention are very

satisfying; they include saving lives, preventing unnecessary illness and costs, and

helping patients free themselves from a deadly addiction.

Modifying your office environment to facilitate clinical tobacco intervention will

prompt you and your staff to discuss smoking with every patient. Your NDA or

National Tobacco Control Group may be able to supply your office with smoking

status labels and educational materials.

38

Involve your office

staff in labelling

patient's charts

Your office staff can assist

you by asking all patients

about their smoking

status and then labelling

the patient's chart with a

smoking-status label. This

will help remind you on

follow-up to discuss

smoking with each

patient. It has been

shown that repeated

brief discussions about

smoking are more

effective in helping

patients quit than one

intensive session.

Provide materials in your waiting area

Have stop-smoking posters and pamphlets in your dental practice for patients to

read while they are waiting to see you.This may encourage them to quit, or at least

to consider quitting. It may also provoke questions that will lead to a quit attempt.

The local or national stop-smoking programme can supply you with educational

materials. Most of the printed materials are usually free to health professionals.

Follow-up

Once a patient has decided to quit, you can help them to remain motivated and

smoke-free by scheduling follow-up visits or phone calls.Your office staff can help

here too by mentioning smoking at dental visits for several years after the patient

has quit.

Counselling

For patients who need it, provide counselling sessions. Discuss their feelings and

concerns about quitting. Suggest methods of dealing with cravings, avoiding weight

loss and using stop-smoking medications if applicable.

If the patient need further help it is best to refer the patient to a smoking cessation

clinic if one exists. However, the majority of countries will not have specialised

smoking cessation clinics. Here is an opportunity for oral health professional

organisations, in combination with the other health professional organisations to

advocate for the establishment of evidence-based national smoking cessation clinics.

Stop-Smoking Medication

If the local legislation permits you can prescribe or recommend stop-smoking

medications when appropriate, and advise your patients on how to best use them.

Nicotine Replacement Therapy (NRT) is the use of a product containing nicotine

to replace the nicotine previously taken in by smoking. NRT decreases withdrawal

symptoms and improves cessation outcomes for many people. NRT is not the

mainstay of smoking cessation but is an effective supplement to behavioural

interventions and good support. NRT is available as nicotine patches, nicotine gum,

nicotine nasal spray and nicotine inhaler.

It is known that NRT approximately doubles the chance of success in stopping

smoking. Behavioural support on top of pharmacokinetics

further increases the chance of success. In fact,

research indicates that the more support provided

to the patient the higher the cessation rates (42).

Talk to smoking patients about quitting

at each visit

Even if you only ask them whether they are ready to

quit at each visit, the message is

clear. As their dentist, let

them know you are

concerned about the

health risks of continuing

to smoke. Mention the

conditions caused by

smoking that are

relevant to each

patient. A patient

who is not interested

in quitting smoking

may change their mind

when faced with the prospect

of improving their overall health.

“

”

...advisingpatients to

quit smoking can be the

single mostimportant

servicedentists

can providefor theirpatient’s

overallhealth...

4. Oral HealthProfessionalAssociations andTobacco Control

I n f l u e n c i n g

behaviour, public

opinion or a

government policy

and encouraging actions that

promote good health can be

summarised under the term

"advocacy". Advocacy is a

respected and recognised

tool for non-governmental

organisations and public

health professionals that

helps in their activism for

better health.

Many health professionals,

however, are not familiar with

the techniques and tools of

advocacy and don’t know

how to increase the impact of

their work with suitable

approaches from the

"advocacy tool kit". The

advocacy cycle offers a model

to start the planning process

for any campaign.

Define aimsWhat do you want to change ?

Analyse the situationIndentify issues and opportunities for change?

Indentify Target GroupWho should be influenced?

Who can help in the process?

Choose approachesAppropriate for target group?

Which messages

Adapt the planModified aims?

Different approaches?Timing?

Evaluate the planOutcome as desired?

Problems?

Plan activitiesWho? What? When?

How? Resources?

Implement the plan

41

Advocacy in Public Health

Rob H Beaglehole & Habib M Benzian

42

...Change ismore likely tocome aboutif more

people andorganisationsare involved...

Advocacy can be done on a number of different levels such as: media work, public

campaigns, press releases, policy statements, personal meetings, organising

hearings and consultations etc. But the key to successful advocacy lies in

recognising that change is more likely to come about if many people and

organisations are actively involved.

Advocacy can be done and may be effective on different levels:

• Individual – direct counselling and support to patients;

• Workplace – creating a smoke free environment, encouraging colleagues to

stop smoking;

• Community – promoting smoke free public places, developing local policies

• National – influencing national legislation and policies, creating awareness for

the problem; and

• International – supporting and promoting strong international policy

framework to counter the tobacco epidemic.

Since advocacy is also about getting involved in politics it is essential to have a good

understanding of political decision processes related to health and the different

interest groups and key stakeholders involved. In formulating arguments for the

anti-tobacco cause it is also important to communicate effectively by using the right

language and appropriate, evidence-based information because the language of

politics can differ greatly from the medical or public health jargon.

Key approaches to effective tobacco control

Interventions targeted at individual smokers are only part of the broader spectrum

of strategies to reduce the prevalence of smoking.The following summarises some

key strategies that can make significant contributions to smoking cessation and help

to prevent people from starting to smoke.

Tobacco control involves a range of supply, demand and harm reduction strategies

that aim to improve the health of a population by reducing or eliminating their

consumption of tobacco products and exposure to tobacco smoke. Such a

comprehensive approach could include the following measures (44):

1. Banning tobacco advertising, promotions and sponsorship because they

increase demand, especially among young people;

2. Raising taxes and prices because they effectively lower consumption. This

policy also helps smokers quit and has a particularly higher impact on poor

society groups who smoke more;

43

...The first stepin involving a dentalassociation in tobaccocontrol is to shape theorganisation’sown policies...

3.Tackling tobacco smuggling because it undermines the health policy, supports

organised crime and increases tobacco demand;

4. Moving towards smoke-free places because of the impact on non-smokers and

children who face increased risks of serious disease;

5. Running a mass communications campaign to take away any belief that

smoking is glamorous, normal or desirable;

6. Developing smoking cessation in health care.Tobacco dependency is treatable

with support and drugs such as nicotine replacement therapy and bupropion.

7.Treating tobacco dependency is cost-effective and is every health care

professional's responsibility;

8.Addressing consumer protection issues by improving packaging, using health

warnings and providing ingredient information; and

9. Reducing harm to those that continue tobacco or nicotine use.The first aim

should be to stop tobacco use altogether, but less hazardous methods of

providing nicotine should be developed.

Oral Health Professional Associations and Tobacco Control

Habib M Benzian

Oral health teams, like other health professionals, acknowledge more and more

that helping smokers stop is part of their role and one of their key health

responsibilities. It is now formally recognised in many countries that smoking

cessation is part of the practice of dentistry and many oral health professional

organisations have implemented appropriate polices to support this.

The first step in involving a dental association in tobacco control is to shape the

organisation’s own policies.There are various examples and templates available for

doing this, some of them have been developed and are provided by the FDI.

The FDI World Dental Federation and Tobacco Control

The FDI Mission to "promote optimal oral and general health for all peoples" includes

by implication a commitment to tobacco control. Acting on behalf of National

Dental Associations on the international level, the FDI has recognised the

importance of engaging the dental profession in tobacco control issues.

In 1996 a Special Committee for Tobacco was established advising the FDI on

action required. One of the first steps was the development of a Policy Statement

on tobacco that has since become the basis of activities and reference for many

member associations of the FDI.

44

The key points of the statement are the recognition of tobacco as a serious risk

to health and oral health, the necessity to integrate tobacco issues in all education

and the protection of children by preventing early initiation and exposure to

tobacco smoke.

FDI POLICY STATEMENT ON TOBACCOTOBACCO IN DAILY PRACTICE

The use of tobacco is harmful to general health as it is a common cause ofaddiction, preventable illness, disability and death.The use of tobacco causesan increased risk for oral cancer, periodontal disease and other deleteriousoral conditions and it adversely affects the outcome of oral health care.

The FDI urges its Member Associations and all oral healthprofessionals to take decisive actions to reduce tobacco useand nicotine addiction among the general public.The FDI also urges all oral health professionals to integratetobacco use prevention and cessation services into theirroutine and daily practice.

TOBACCO IN ALL EDUCATION

Brief interactions, for example, by identifying tobacco users, giving directadvice, supportive material and follow-up, all have a significant impact on thepatients’ use of tobacco products.The FDI urges all oral health institutions and all continuingeducation providers to integrate tobacco-related subjectsinto their programmes.

PROTECT THE CHILDREN

The adverse consequences of environmental tobacco smoke are particularlysevere for children - and life long.The FDI strongly endorses and promotes public andprofessional education and policies that prevent and/orreduce the exposure to tobacco smoke for infants, childrenand young people.

PREVENT THE INITIATION

More than eighty percent of adults who use tobacco, started their use oftobacco before the age of eighteen. Use of tobacco among children andyouths easily produces a nicotine dependency, the risk of which is vastlyunderestimated by young people.The FDI vigorously supports all measures that endeavour toprevent the initiation of tobacco use by young people anddissuade initiation by adults.

45

The FDI is an active member of the Framework Convention Alliance (FCA), the

global network of international and civil society organisations that gave input to

WHO FCTC and follow the implementation process critically. The FDI has

participated in the negotiating and advocacy process from the beginning, including

all preparatory meetings and hearings.The FDI fully endorses the objective of the

WHO FCTC "to protect present and future generations from the devastating

health, social, environmental and economic consequences of tobacco consumption

and exposure to tobacco smoke." The FDI has organised and participated in

numerous national and international conferences and tobacco control issues are a

regular feature at all Annual World Dental Congresses.

As part of the international activities the FDI supports member associations in

their tobacco control activities by providing sample letters, advice and guidance in

national advocacy issues and by promoting the WHO policies in this regard.

National Dental Associations and Tobacco Control

A recent survey clearly indicated that there is an urgent need to place tobacco control

initiatives on the oral health policy agenda of both National Dental Associations

(NDAs) and Ministry’s of Health (45). A range of policy opportunities exists to

facilitate greater involvement of the dental profession in tobacco control activities.

A number of NDAs have made promising progress in raising tobacco control issues

amongst their members. However, the opportunity clearly exists for this role to be

expanded to other countries around the world (46). NDAs are in an ideal position

to influence both the behaviour and attitude of their members. Importantly, they are

also able to act as advocates for policy development in tobacco control policy more

generally.The WHO has outlined a variety of actions that NDAs can implement in

support of tobacco control (47).

The conditions need to be created in which the dental team are enabled to

become more actively involved in tobacco control. This requires leadership and

appropriate action from NDAs. Dissemination of models of good practice in

countries where some progress has been achieved would make a valuable

contribution in moving the agenda forward.

The Code of Practice for oral health professional organisations intobacco control

This FDI Policy Statement is based on a set of recommendations developed by the

World Health Organization.The statement outlines 14 very tangible and practical

steps that every dental association can take on the way to engage effectively in

tobacco control.

46

The Code of Practice includes preventative aspects, organisational measures

(tobacco free environments & congresses), research aspects (evaluation of

tobacco habits), financial (allocate a budget to tobacco control activities), advocacy

(political work, World No Tobacco Day) and other issues that every dental

association can implement.

47

Code of Practice on tobacco control for oral health professional organisations

In order to contribute actively to the reduction of tobacco consumption andinclude tobacco control in the public health agenda at national, regional andglobal levels, it is recommended that oral health organisations will:

1. Encourage and support their members to be role models by not usingtobacco and by promoting a tobacco-free culture.

2. Assess and address the tobacco consumption patterns and tobacco-control attitudes of their members through surveys and theintroduction of appropriate policies.

3. Make their own organisations’ premises and events tobacco-free andencourage their members to do the same.

4. Include tobacco control in the agenda of all relevant health-relatedcongresses and conferences.

5. Advise their members to routinely ask patients and clients about tobaccoconsumption and exposure to tobacco smoke by using evidence-basedapproaches and best practices and give advice on how to quit smokingand ensure appropriate follow-up of their cessation goals.

6. Influence health institutions and educational centres to include tobaccocontrol in their health professionals' curricula, through continuededucation and other training programmes.

7. Actively participate in World No Tobacco Day every 31 May.

8. Refrain from accepting any kind of tobacco industry support – financialor other – from investing in the tobacco industry, and encourage theirmembers to do the same.

9. Whenever possible, organisations will give preference to partners whohave a policy indicating that they refrain from accepting any kind oftobacco industry support – financial or other – from investing in thetobacco industry and encourage their members to do the same.

10.Prohibit the sale or promotion of tobacco products on their premises,and encourage their members to do the same.

11.Actively support governments in the process leading to signature,ratification and implementation of the WHO Framework Conventionon Tobacco Control.

12.Dedicate financial and/or other resources to tobacco control – includingdedicating resources to the implementation of this code of practice.

13.Participate in the tobacco-control activities of health professionalnetworks.

14. Support campaigns for tobacco-free public places.

48

Country Case Studies

Kenya: International advocacy helped in the

WHO FCTC ratification

The fight against tobacco is difficult because the tobacco industry is always

corrupting scientific information and amplifying perceived economic benefits of

their trade. Sound evidence on the negative health effects of tobacco is

nevertheless available from health professionals and trusted organisations that are

leaders in their respective fields. Their opinions and recommendations are taken

seriously and their persistent involvement in advocacy is therefore invaluable.

The FDI, for example provided solid support during the period prior to Kenya’s

signing and ratification of the WHO FCTC. Other professional bodies also sent

petitions to our Ministry and such support strengthened our case for ratifying the

WHO FCTC.The credibility of a professional organisation is valuable currency in

advocacy and it should be used when the need arises. In Kenya we know only too

well how that value impacts on decision making. Kenya’s respect for science and

professionalism led us to be the only African country (and one out of two in the

world) to sign and ratify the WHO FCTC on the same day!

I would urge professional bodies to emulate the FDI in its involvement in lobbying

governments to make policy decisions that improve the health environment for

their citizens. I can confirm that this approach works and is one of the best ways

for us to impact on public health.

Dr Ahmed OgwellHead, Division of Noncommunicable Diseases and Head of Secretariat,National Tobacco-Free Initiative Committee (NTFIC),Ministry of Health,Nairobi, Kenya

49

GermanyGovernment and WHO for Tobacco Control

The prevention of tobacco use, particularly in children and adolescents, presents

one of the most important responsibilities health profession organisations have

world-wide. The epidemiological data on morbidity and mortality as a result of

tobacco consumption are well known. The influence of tobacco use on general

health is also well documented. In comparison, the effects of tobacco use on oral

health, such as periodontal disease and oral cancer receive less attention.

The German Dental Association has been supporting the FDI for several years on

an international level. For example, by participating in the negotiation of the WHO

FCTC. In 2002, the German Dental Association’s Policy Statement on Tobacco was

adopted. Political lobbying concerning tobacco control programmes occurred

primarily at the Ministerial level.

Apart from advocacy at this level, the training of oral health professionals in

smoking cessation advice is also very important, since dentists are the most

frequently consulted specialists in Germany. Therefore dental practitioners are

ideally placed to provide information on consumption of tobacco and alcohol, on

changing behaviour and on early detection of diseases.The integration of evidence-

based tobacco control initiatives into dental education and health professional’s

curricula is also very worthwhile and should be encouraged by National Dental

Associations around the world.

Dr. Dietmar OesterreichVice PresidentGerman Dental AssociationBerlin, Germany

50

India: Collaboration between the NDA,Government and WHO for Tobacco Control

Far too few health professionals are actively engaged in tobacco control. Health

care professionals need to hear messages from other health professionals who are

already active in tobacco control. Dentists will be receptive to messages that come

from their professional organisations.

The Indian Dental Association, which has 45,000 active and 10,000 student

members, has drafted a tobacco control strategy and advocacy plan.The goal of the

plan is to get members involved in a full range of tobacco control activities. The

Association is planning on running one-day tobacco cessation training courses.

Publishing scientific articles on the effectiveness of dentist delivered tobacco

cessation interventions in journals and newsletters is another way of encouraging

involvement.The need to conduct national wide surveys of association members is

also to be encouraged. Questions should be asked about self-use of tobacco, the

extent to which they provide tobacco counselling and cessation treatment, and

their training requirements in tobacco control interventions.

There are both direct and indirect ways that the FDI,WHO, Health Ministry, and

the Government of India can do to encourage and enlist dentists into taking more

responsibility for tobacco control. The Health Ministry and WHO are trying to

advocate and fund training programmes for dentists on tobacco counselling and

cessation in association with the Indian Dental Association. The Health Ministry

will also coordinate and guide new curricula that will be introduced into dental

colleges in India, including tobacco control activities/advocacy and tobacco

cessation treatment.

Dr Mihir N. ShahProfessor of Periodontology and Public Health,Ahmenabad, India

51

South AfricaGovernment and WHO for Tobacco Control

South Africa is in a fortunate position regarding tobacco products in that the

support received from the Government has been fantastic. Laws have been passed

which outlaw tobacco advertising on TV and radio, and all packaging for tobacco

products has to include health warnings.Tobacco, although still relatively cheap by

world standards, has increased dramatically in price due to increasing tobacco

taxes. It is illegal to sell tobacco to minors (under 18 years of age).

The South African Dental Association’s position on tobacco is based directly on the

FDI tobacco policy statement.We are active participants on World No Tobacco Day

and have been attendees at various functions organised to celebrate the day and to

draw public attention to the evils of smoking.The South African Dental Journal has

often reported on the risks of oral cancer and periodontal disease with possible

tooth loss as a result from smoking. I am periodically able to get an oral health

perspective into the lay media around World No Tobacco Day, as journalists are

keen for input from all healthcare providers around this occasion.

Along with the good news we have to report some bad. Our northern neighbour,

Zimbabwe, has huge economic problems and is a large producer of tobacco.A lot

of tobacco products are smuggled into South Africa thereby decreasing the impact

of South Africa’s restrictive legislation. We are keen to see a strict and rapid

implementation of the WHO FCTC with its clauses on tobacco smuggling.This will

help in cutting down the thriving black market that is providing cheap tobacco.

Dr Neil CampbellExecutive Director,South African Dental Association,Houghton, South Africa

52

Fiji: Personal experience of a dental student in quitting

"I had been smoking for 11 years and started when I was in the first year of

secondary school. Influenced by the pride of a "step further" in my education and

the pressure from my relatives and peer group, I took up smoking. This habit

became worse due to the increased freedom I got in secondary school. I had been

enrolled at the Fiji School of Medicine for three years in 2004 but despite listening

to lecturers and friend’s advice on quitting, I continued to smoke.The turning point

was when I became a group member from my dental class that was actively involved

in producing the smoking cessation related aids for the health festival.This activity,

together with developing our skills of communication, collaboration and

management within groups, improved our understanding of the hazardous effects

of smoking on oral health, screening for oral cancer and most importantly how we

as dental personnel can help patients quit. It was during this exercise of gathering

evidence-based information for our learning portfolio and realizing the effect of

smoking on my health that I quit. It took me almost a week to refuse a cigarette

and during the last week of smoking I had decreased numbers greatly until I

stopped completely. It was not easy but I am proud to have quit and to have

become a living role model. My group members were fascinated to see me go

through the process of successfully quitting. I hope you can quit too!"

Testimony provided by

Dr Bernadette PushpaangaeliSchool of Public Health & Fiji Dental Associaiton,Suva, Fiji

53

Dentistry Against Tobacco, a Swedishorganisation for oral health professionals

Dentistry against Tobacco (DAT) works as a uniting body for employees in dentistry

who in their profession, wish to work actively to reduce the use of tobacco in

society and spread knowledge among colleagues about the complex nature and

causes of tobacco habits as well as its adverse effects.We also try to make tobacco

education a part of the curricula in the basic training and education of oral health

professionals.

Since 1992 DAT has been an active part of the Swedish national network against

tobacco use. DAT is in close co-operation with the FDI and is also a member of the

Framework Convention Alliance in connection with the WHO FCTC negotiations.

At annual Swedish dental congresses, DAT has arranged meetings on tobacco issues

with national and international participation, sometimes presenting studies and

results done with economic support from the organisation. We have produced

material that makes it possible to participate and influence participants at this and

other oral health congresses.

Tobacco or Health (Tobak eller Hälsa) is the name of the journal published

quarterly by five health promotion organisations, in which DAT contributes with

written material.This journal is sent to private clinics and to every County Council

for distribution among dental clinics. DAT initiated and was also one of the

publishers behind the handbook "Tobacco and Teeth", the so-called "Monkey-book"

(the cover consisted of a big-smiling monkey showing all its teeth!) which was sent

to all active dentists and hygienists nation-wide.

In the education of dental hygienists in Stockholm, knowledge about tobacco and

its adverse effects have been on the curricula for the past two years and is highly

appreciated by the students. DAT participate with lectures and material in other

courses, for example post graduate, on tobacco and its adverse effects on the

national and regional levels.

Dr Örjan ÅkerbergSecretary, Dentistry against Tobacco-Sweden,Stockholm, Sweden

“”

...The success of theWHO FCTC as a tool for public health will

depend on the energyand political

commitment that wedevote to implementing

it in countries in thecoming years.

A successful result will be global publichealth gains for all.

5. Recommendationsto Oral HealthProfessionalOrganisations

55

Rob H Beaglehole, Habib M Benzian & Poul Erik Petersen

National Dental Associations have an important advocacy role to play in promoting

policy reforms and by highlighting the important role dental professionals can play

in tobacco control. It is suggested that where possible countries should produce

guidelines for oral health professionals, modelled on the recent – Helping smokers

to stop: a guide for the dental team (48). In addition, more in depth training at both

undergraduate and continuing education levels is required to expand the skills and

knowledge of oral health professionals.

Recommendations to oral health organisations at the global, national, and local levels

are proposed.There is an urgent need to put tobacco control initiatives, including

cessation programmes, on the oral health agenda.The World Health Organization

and FDI World Dental Federation can provide the leadership for this action.

The following recommendations are made to national oral health organisations:

Global

• That oral health professional organisations and their members play a leading

role in ensuring the implementation of the WHO FCTC at a national level;

• That tobacco cessation programmes are placed on the global oral health

agenda by FDI and WHO.

National

• That NDAs advocate for oral health as an integral part of general health;

• That the NDA facilitates the development of guidelines and practices, especially

around smoking cessation activities;

• That the whole oral health team is encouraged and trained by NDAs in

tobacco prevention activities;

56

• That adequate training on tobacco control and cessation initiatives be given in

dental schools;

• That NDAs lobby governments so that dentists can prescribe NRT free or at

subsidised rates;

• That a national committee of experts on tobacco issues within the NDA is

established at national level; and

• That NDAs should link with other health professional organisations to share

experiences, plan joint activities and increase impact in advocacy. Such a group

could be formalised as a "National Tobacco Advocacy Group", a model that has

been very successful in some countries (i.e. Sweden, Canada).

At the individual level, oral health professionals:

• Should be tobacco- free and act as positive role models; and

• Should help tobacco users overcome their addiction and

educate the population on the harm of tobacco use and

exposure to second-hand smoke.

At the community/local level, oral health professionals can:

• Work for inclusion of tobacco and oral health issues in

school health programmes and provide support to

school teachers and other staff in curriculum

development;

• Promote tobacco-free workplaces and tobacco-free

public transport;

• Persuade local governments to ban tobacco

advertising and promotion;

• Extend the availability of tobacco cessation resources;

• Visit schools to discuss the impact of tobacco and

industry tactics with students, staff and even with

parents; and

• Contribute to health related columns in local

newspapers and/or by appearing on the local radio

and television.

Health professional organisations are responsible

for action within and outside their organisations.

Among the membership, it is recommended that

oral health organisations:

57

• Carry out regular surveys of members’ tobacco consumption habits and

attitudes towards tobacco consumption;

• Disseminate the results among the members;

• Set up a tobacco control group within the professional association;

• Educate members about tobacco;

• Make the premises and meetings smoke- and tobacco-free;

• Keep members up to date and trained on cessation methods; and

• Review investment portfolios of their organisations to eliminate tobacco holdings.

Outside their own organisation and membership, it is recommended that oral

health organisations:

• Contribute to the formulation of national plans of action for tobacco control;

• Work with other health professional organisations to develop a common

position on tobacco control and consider establishing a coalition;

• Campaign for tobacco-free health care facilities to make non-smoking the norm;

• Influence the content of health professional education and motivate students

by setting up a tobacco control body;

• Carry out surveys and prepare regular reports on tobacco related issues

highlighting tobacco control priorities; and

• Lobby for public and private reimbursement for cessation counselling.

Glossary of Terms

Resources and Links

58

www.ash.org.ukAn excellent source of up to date information on all aspects of smoking, with numerous links to relevantresources and documents.

www.cdc.gov/tobaccoThis website provides practical information for those who want to stop smoking as well as an overviewof tobacco information.

http://www.ensp.org/The European Network for Smoking Prevention (ENSP) aims to create greater coherence amongsmoking prevention activities and to promote comprehensive tobacco control policies at both thenational and European level.

http://factsheets.globalink.org/Tobacco Control fact sheets from Globalink.

ASH Action on Smoking and HealthCDO Chief Dental OfficerCPI Community Periodontal IndexDAT Dentistry Against TobaccoENSP European Network for Smoking Prevention FCA Framework Convention AllianceFCTC Framework Convention on Tobacco ControlFDI FDI World Dental FederationGYTS Global Youth Tobacco SurveyHDA Health Development AgencyIADR International Association for Dental Research NCD Non Communicable DiseaseNDA National Dental AssociationNGO Non governmental organisationNRT Nicotine Replacement TherapyTFI WHO Tobacco Free InitiativeUICC International Union Against CancerUSDHHS US Department of Health and Human ServicesWHA World Health AssemblyWHO World Health Organization WNTD World No Tobacco Day

59

www.fdiworldental.orgThe website of the FDI World Dental Federation gives detailed information and background on tobaccouse, oral health and the involvement of the dental profession.

www.givingupsmoking.co.ukThe UK Department of Health tobacco control website which provides details of NHS Stop SmokingServices and other useful information.

http://news.globalink.org/Get the latest tobacco news on the Internet in: English | Français | Deutsch | Español

http://www.paho.org/ENGLISH/HPP/HPM/TOH/tobacco.htmThe Pan American Health Organisation (PAHO) has produced a document on the WHO FCTC - TheFramework Convention on Tobacco Control: Strengthening Health Globally.

www.quitnow.info.auHelpful advice on quitting is provided by this excellent website of the Australian National TobaccoCampaign.

http://strategyguides.globalink.org/The website has been designed as a "One Stop" resource for tobacco control advocates planning andworking to achieve strong, comprehensive tobacco control laws. The website contains twocomplementary strategy-planning guides: Strategy Planning for Tobacco Control Advocacy, and StrategyPlanning for Tobacco Control Movement Building. Each guide, continuously updated, provides both practicalguidance and links to other useful guides and resources.

www.tobacco-control.orgThe website of the Tobacco Control Resource Centre which works in partnership with national medicalassociations across Europe, supporting them in their efforts to educate their members, help patients andinform public policy with respect to tobacco.

http://www.tobaccopedia.org/The Online Tobacco Encyclopaedia

http://www.who.int/tobacco/en/The tobacco section of the WHO website which providing a wealth of information on tobacco.

http://www.who.int/tobacco/resources/publications/tobaccocontrol_handbook/en/The WHO Tobacco Free Initiative (TFI) has launched a new publication in the series 'Tools for advancingtobacco control in the 21st century' with the title: Building blocks for tobacco control: a handbook.

http://www.who.int/oral_healthThe strategies and approaches to oral disease prevention and health promotion recommended by theWHO Global Oral Health Programme are outlined.Tobacco-related oral diseases are priority issue andthe efforts to control such disease are detailed. Several policy reports and publications are available.

Francophone tobacco links:

http://www2.gosmokefree.ca/francais/index.aspSite contre le tabagisme de Santé Canada, also in English.

http://cnct.orgComité National contre le Tabagisme, France.

http://www.at-suisse.chAssociation Suisse pour la prévention du tabagisme (also in German and Italian).

References

60

Preamble

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Chapter 4

44. Jamrozik, K. Population strategies to prevent smoking. British Medical Journal 2004; 328: 759-762.

45. Beaglehole, R.H.The role of oral health professionals in tobacco control in OECD countries: policiesand initiatives. Master’s Thesis. University College London, 2003.

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47. Petersen PE. The World Oral Health Report. Continuous improvement of oral health in the 21stcentury: the approach of the Global Oral Health programme. Geneva:World Health Organization, 2003.Available from: http://www.who.int/oral_health/publications/report03/en (accessed April 2005).

Chapter 5

48. Beaglehole R.H, Watt R. Helping smokers to stop: a guide for the dental team. London: HealthDevelopment Agency, 2004: http://www.publichealth.nice.org.uk/page.aspx?o=502735 (accessed April2005).

General references:

American Cancer Society. Engaging Doctors in Tobacco Control 2003. Inwww.strategyguides.globalink.org (accessed April 2005).

Beaglehole R.H, G, Tsakos, Watt R. Tobacco control and the dental profession: a survey of OECDNational Dental Associations. International Dental Journal 2005 (In press).

Doll, R., Grey, R., Peto, R., Wheatly, K. Tobacco related diseases. Journal of Smoking Related Diseases1994; 1, 3-13.

Jamison, DT., Frenk J., Knaul, F. International collective action in health: objectives, functions, and rationale.Lancet 1998; 351, 514-517.

John J,Thomas D, Richards D. Smoking cessation interventions in the Oxford region: Changes in dentists’attitudes and reported practices 1996-2001. British Dental Journal 2003;195: 270-275.

Petersen PE. Global Framework Convention on Tobacco Control: The implications for Oral Health.Community Dent Health 2003;20:137-8.

Petersen PE.Tobacco and oral health - the role of the World Health Organization. Oral Health Prev Dent2003;1:309-15.

Royal College of Physicians Tobacco Advisory Group Nicotine Addiction in Britain. London: RoyalCollege of Physicians 2000.

WHO Framework Convention on Tobacco Control.Available from:http://www.who.int/tobacco/framework/en (accessed April 2005).

Winn D.Tobacco use and oral disease. Journal of Dental Education 2001;65:306-312.

Appendix 1

63

Advocacy Letter Example

Oral Health Organisation letter heading

Dear xxx (please insert title as appropriate),

Tobacco kills more than xxx (number) people each year in xxx (your country) and

smoking remains the largest single cause of preventable death and disease in the

developed countries. On the occasion of World No Tobacco Day (31 May 2005),

(oral health professional organisation) wish to urge you to take the following

action:

1. Increase accessibility to tobacco cessation treatment for smokers (including the

training of health professionals and the development of a national network of

tobacco cessation treatment services) as well as improving accessibility to nicotine-

replacement therapies and removing inequalities in the provision of these services;

2. Successfully implement and enforce the most stringent measures within the

WHO Framework Convention on Tobacco Control in order to protect public

health (ADD link);

3. Take the required action to fully protect non-smokers from the detrimental

effects of tobacco smoke, because tobacco smoke is a toxic, carcinogenic mutagen

and also a repro-toxic substance.

The xxxx (country) Oral Health Professional Organisation comprising xxx

(number) members committed to reducing death and disability as the result of

tobacco use, demand that the government enacts through policies to address

tobacco use with the aim of protecting all citizens from a lifetime of preventable

addiction and disease.

Yours faithfully,

Health Professional Organisation xx

Name of Signatory

Number of Members

Signature

From the WHO FCTCRatification Planning Guide

64

This guide was developed by the Framework Convention Alliance to support

NGOs and other organisations in their activities. By answering the key questions

listed below as part of the planning and advocacy cycle the planning and

implementation of tobacco control activities may become easier and more

effective. More information can be found at www.fca.org

1. Describe your advocacy objective as specifically as possible

2.Who has the direct authority to make it happen? [Identify the target audience]

3.What do they need to hear to persuade/cause/force them to make it happen?

[Messages]

4. How do we make these messages speak both to the brain and to the heart of the target

audience?

5.Who are the most effective messengers for our target audience? Who will the authorities

most trust or listen to?

6.What are the most effective means for delivering our messages? Lobbying? Focused

media advocacy? Protest? A combination of these?

7.What are effective ways to gain the media's attention with stories that best convey our

messages?

8.What other materials might we need to develop for our ratification campaign?

World Health Organization

© FDI World Dental Press and the FDI

Tobacco or

Oral HealthAn advocacy guide for oral health professionals